Men left behind – an analysis of 12 years of HIV treatment in South Africa
South Africa’s national antiretroviral treatment programme has successfully reduced deaths and enabled people with HIV to maintain good health – but men are far less likely to benefit.
The study, by the International Epidemiology Databases to Evaluate AIDS-Southern Africa Collaboration, found South Africa’s growing national ART programme is continuing to enable the majority of people living with HIV and on treatment to achieve viral suppression. It has also brought the death rate among people with HIV on long-term treatment to a similar level as that in the general population.
However, the analysis highlights glaring disparities between genders, with men less likely to be on treatment than women, more likely to start treatment late and more likely to have tuberculosis (TB). As a result, the death rate of men engaged in treatment over the 12-year period was found to be nearly double that of women on treatment.
South Africa has the largest ART programme in the world, with 3.39 million people on treatment in 2015. With all 7.1 million people living with HIV in South Africa now eligible for ART, in line with UNAIDS and World Health Organization guidelines, studies such as this one are essential to assess the quality of care being received.
The analysis examined ID-linked patient records of adults starting HIV treatment between 2004 and 2015. In total, 72,812 people from five large South African ART programmes were included, just under half of whom were male (43%). It found around three-quarters of patients were alive 12 years after beginning treatment. But, when further broken down by gender, this translated to around 70% of male patients, compared to around 80% of female patients.
Overall, the death rate among people on HIV treatment was higher than among people without HIV. But after four years of treatment, death rates normalised between people on treatment and the general population’s death rate.
The analysis also highlighted how, despite increasing patient numbers, 86% of all people on ART who were tested for viral suppression achieved it; close to the UNAIDS target of 90% suppression. This means the majority of people included in the analysis were in good health and unable to pass HIV on to others.
However, the study found continuing disparities between men and women, with men showing poorer engagement at each stage of the treatment cascade.
The proportion of men starting ART was found to be lower than women. This remained stagnant, with no increase across the entire 12 years.
Men were also found to start ART at older ages (median 38 years vs. 33 years) and with more advanced HIV than women. In addition, twice the proportion of men compared with women initiating ART between 2013 and 2015 were found to have TB. This suggests national campaigns are urgently needed to increase testing and earlier ART initiation among men in South Africa.
This study was strengthened by its large sample size, the duration of analysis, and the comparison it made with HIV-negative death rates. Nonetheless, four of the five cohorts studied were urban, and data was only analysed if patients had an ID number, meaning it may not be wholly representative.